Appointment Request
If you are having a dental emergency, please make your appointment by calling our office at
757-497-4825
.
When requesting an appointment, please keep in mind our office hours are:
Monday 8am - 6pm
Tuesday 8am - 5pm
Wednesday 8am - 6pm
Thursday 8am - 5pm
Friday 8am - 2pm (we are only open the first Friday of the month)
Name
*
Phone
*
Email
*
Preferred Method of Contact
Phone
Email
Reason for Appointment
*
Preferred Provider
No Preference
Dr. Fernandez
Dr. Cox
Kelly
Melanie
Grace
Julie
Requested Day of Week
Monday
Tuesday
Wednesday
Thursday
or Date
Requested Time of Day
Early as Possible
10am - 1pm
2pm - 4pm
Late as Possible
Whom may we thank for referring you?
Friend
Relative
Co-Worker
Insurance
Referring person
We will contact you by your stated preferred method when your request has been fulfilled.
We look forward to taking care of you